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Health insurance

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From Wikipedia, the free encyclopedia
Health insurance or medical insurance (also known as medical aid in South Africa)
is a type of insurance that covers the whole or a part of the risk of a person
incurring medical expenses. As with other types of insurance, risk is shared among
many individuals. By estimating the overall risk of health risk and health system
expenses over the risk pool, an insurer can develop a routine finance structure,
such as a monthly premium or payroll tax, to provide the money to pay for the
health care benefits specified in the insurance agreement.[1] The benefit is
administered by a central organization, such as a government agency, private
business, or not-for-profit entity.

According to the Health Insurance Association of America, health insurance is

defined as "coverage that provides for the payments of benefits as a result of
sickness or injury. It includes insurance for losses from accident, medical
expense, disability, or accidental death and dismemberment".[2]: 225

Background

This article has multiple issues. Please help improve it or discuss these issues on
the talk page. (Learn how and when to remove these messages)
This section needs additional citations for verification. (June 2021)
The examples and perspective in this section may not represent a worldwide view of
the subject. (June 2021)
A health insurance policy is:

A contract between an insurance provider (e.g. an insurance company or a

government) and an individual or his/her sponsor (that is an employer or a
community organization). The contract can be renewable (annually, monthly) or
lifelong in the case of private insurance. It can also be mandatory for all
citizens in the case of national plans. The type and amount of health care costs
that will be covered by the health insurance provider are specified in writing, in
a member contract or "Evidence of Coverage" booklet for private insurance, or in a
national [health policy] for public insurance.
(US specific) In the U.S., there are two types of health insurance – tax payer-
funded and private-funded.[3] A private-funded insurance plan example includes an
employer-sponsored self-funded ERISA (Employee Retirement Income Security Act of
1974) plan. Typically, these companies promote themselves as having ties to major
insurance providers. However, in the context of an ERISA plan, these insurance
companies do not actively participate in insurance practices; instead, they handle
administrative tasks. Consequently, ERISA plans are exempt from state regulations
and fall under federal jurisdiction, overseen by the US Department of Labor
(USDOL). Specific details about benefits or coverage can be found in the Summary
Plan Description (SPD). Should there be a need for an appeal, the process typically
involves initiating it through the insurance company and then reaching out to the
Employer's Plan Fiduciary. If a resolution is still not achieved, the decision can
be escalated to the USDOL for review to ensure compliance with ERISA regulations,
and, if necessary, legal action can be taken by filing a lawsuit in federal court.
The individual insured person's obligations may take several forms:[citation
needed]
Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to
the health plan to purchase health coverage. (US specific) According to the
healthcare law, a premium is calculated using 5 specific factors regarding the
insured person. These factors are age, location, tobacco use, individual vs. family
enrollment, and which plan category the insured chooses.[4] Under the Affordable
Care Act, the government pays a tax credit to cover part of the premium for persons
who purchase private insurance through the Insurance Marketplace.[5]: TS 4:03
Deductible: The amount that the insured must pay out-of-pocket before the health
insurer pays its share. For example, policy-holders might have to pay a $7500
deductible per year, before any of their health care is covered by the health
insurer. It may take several doctor's visits or prescription refills before the
insured person reaches the deductible and the insurance company starts to pay for
care. Furthermore, most policies do not apply co-pays for doctor's visits or
prescriptions against your deductible.
Co-payment: The amount that the insured person must pay out of pocket before the
health insurer pays for a particular visit or service. For example, an insured
person might pay a $45 co-payment for a doctor's visit, or to obtain a
prescription. A co-payment must be paid each time a particular service is obtained.
Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-
payment), the co-insurance is a percentage of the total cost that an insured person
may also pay. For example, the member might have to pay 20% of the cost of a
surgery over and above a co-payment, while the insurance company pays the other
80%. If there is an upper limit on coinsurance, the policy-holder could end up
owing very little, or a great deal, depending on the actual costs of the services
they obtain.
Exclusions: Not all services are covered. Billed items like use-and-throw, taxes,
etc. are excluded from admissible claim. The insured are generally expected to pay
the full cost of non-covered services out of their own pockets.
Coverage limits: Some health insurance policies only pay for health care up to a
certain dollar amount. The insured person may be expected to pay any charges in
excess of the health plan's maximum payment for a specific service. In addition,
some insurance company schemes have annual or lifetime coverage maxima. In these
cases, the health plan will stop payment when they reach the benefit maximum, and
the policy-holder must pay all remaining costs.
Out-of-pocket maximum: Similar to coverage limits, except that in this case, the
insured person's payment obligation ends when they reach the out-of-pocket maximum,
and health insurance pays all further covered costs. Out-of-pocket maximum can be
limited to a specific benefit category (such as prescription drugs) or can apply to
all coverage provided during a specific benefit year.
Capitation: An amount paid by an insurer to a health care provider, for which the
provider agrees to treat all members of the insurer.
In-Network Provider: (U.S. term) A health care provider on a list of providers
preselected by the insurer. The insurer will offer discounted coinsurance or co-
payments, or additional benefits, to a plan member to see an in-network provider.
Generally, providers in network are providers who have a contract with the insurer
to accept rates further discounted from the "usual and customary" charges the
insurer pays to out-of-network providers.
Out-of-Network Provider: A health care provider that has not contracted with the
plan. If using an out-of-network provider, the patient may have to pay full cost of
the benefits and services received from that provider. Even for emergency services,
out-of-network providers may bill patients for some additional costs associated.
Prior Authorization: A certification or authorization that an insurer provides
prior to medical service occurring. Obtaining an authorization means that the
insurer is obligated to pay for the service, assuming it matches what was
authorized.[disputed – discuss] Many smaller, routine services do not require
authorization.[6]
Formulary: the list of drugs that an insurance plan agrees to cover.[7]
Explanation of benefits: A document that may be sent by an insurer to a patient
explaining what was covered for a medical service, and how payment amount and
patient responsibility amount were determined.[6] In the case of emergency room
billing, patients are notified within 30 days post service. Patients are rarely
notified of the cost of emergency room services in-person due to patient conditions
and other logistics until receipt of this letter.[8]
Prescription drug plans are a form of insurance offered through some health
insurance plans. In the U.S., the patient usually pays a copayment and the
prescription drug insurance part or all of the balance for drugs covered in the
formulary of the plan.[5]: TS 2:21 Such plans are routinely part of national health
insurance programs. For example, in the province of Quebec, Canada, prescription
drug insurance is universally required as part of the public health insurance plan,
but may be purchased and administered either through private or group plans, or
through the public plan.[9]

Some, if not most, health care providers in the United States will agree to bill
the insurance company if patients are willing to sign an agreement that they will
be responsible for the amount that the insurance company does not pay. The
insurance company pays out of network providers according to "reasonable and
customary" charges, which may be less than the provider's usual fee. The provider
may also have a separate contract with the insurer to accept what amounts to a
discounted rate or capitation to the provider's standard charges. It generally
costs the patient less to use an in-network provider.

Comparisons
See also: Health system

Health Expenditure per capita (in PPP-adjusted US$) among several OECD member
nations. Data source: OECD's iLibrary[10]
The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares
the performance of the health care systems in Australia, New Zealand, the United
Kingdom, Germany, Canada and the U.S. Its 2007 study found that, although the U.S.
system is the most expensive, it consistently under-performs compared to the other
countries.[11] One difference between the U.S. and the other countries in the study
is that the U.S. is the only country without universal health insurance coverage.
[citation needed]

Life Expectancy of the total population at birth among several OECD member nations.
Data source: OECD's iLibrary[12]
The Commonwealth Fund completed its thirteenth annual health policy survey in 2010.
[13] A study of the survey "found significant differences in access, cost burdens,
and problems with health insurance that are associated with insurance design".[13]
Of the countries surveyed, the results indicated that people in the United States
had more out-of-pocket expenses, more disputes with insurance companies than other
countries, and more insurance payments denied; paperwork was also higher although
Germany had similarly high levels of paperwork.[13]

Australia
Main article: Health care in Australia
The Australian public health system is called Medicare, which provides free
universal access to hospital treatment and subsidised out-of-hospital medical
treatment. It is funded by a 2% tax levy on all taxpayers, an extra 1% levy on high
income earners, as well as general revenue.[citation needed]

The private health system is funded by a number of private health insurance

organizations. The largest of these is Medibank Private Limited, which was, until
2014, a government-owned entity, when it was privatized and listed on the
Australian Stock Exchange.[citation needed]

Australian health funds can be either 'for profit' including Bupa and nib; 'mutual'
including Australian Unity; or 'non-profit' including GMHBA, HCF and the HBF Health
Insurance. Some, such as Police Health, have membership restricted to particular
groups, but the majority have open membership. Membership to most health funds is
now also available through comparison websites. These comparison sites operate on a
commission-basis by agreement with their participating health funds. The Private
Health Insurance Ombudsman also operates a free website that allows consumers to
search for and compare private health insurers' products, which includes
information on price and level of cover.[14]

Most aspects of private health insurance in Australia are regulated by the Private
Health Insurance Act 2007. Complaints and reporting of the private health industry
is carried out by an independent government agency, the Private Health Insurance
Ombudsman. The ombudsman publishes an annual report that outlines the number and
nature of complaints per health fund compared to their market share [15]

The private health system in Australia operates on a "community rating" basis,

whereby premiums do not vary solely because of a person's previous medical history,
the current state of health, or (generally speaking) their age (but see Lifetime
Health Cover below). Balancing this are waiting periods, in particular for pre-
existing conditions (usually referred to within the industry as PEA, which stands
for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to
12 months on benefits for any medical condition the signs and symptoms of which
existed during the six months ending on the day the person first took out
insurance. They are also entitled to impose a 12-month waiting period for benefits
for treatment relating to an obstetric condition, and a 2-month waiting period for
all other benefits when a person first takes out private insurance. Funds have the
discretion to reduce or remove such waiting periods in individual cases. They are
also free not to impose them, to begin with, but this would place such a fund at
risk of "adverse selection", attracting a disproportionate number of members from
other funds, or from the pool of intending members who might otherwise have joined
other funds. It would also attract people with existing medical conditions, who
might not otherwise have taken out insurance at all because of the denial of
benefits for 12 months due to the PEA Rule. The benefits paid out for these
conditions would create pressure on premiums for all the fund's members, causing
some to drop their membership, which would lead to further rises in premiums, and a
vicious cycle of higher premiums-leaving members would ensue.[citation needed]

The Australian government has introduced a number of incentives to encourage adults

to take out private hospital insurance. These include:

Lifetime Health Cover: If a person has not taken out private hospital cover by 1
July after their 31st birthday, then when (and if) they do so after this time,
their premiums must include a loading of 2% per annum for each year they were
without hospital cover. Thus, a person taking out private cover for the first time
at age 40 will pay a 20 percent loading. The loading is removed after 10 years of
continuous hospital cover. The loading applies only to premiums for hospital cover,
not to ancillary (extras) cover.
Medicare Levy Surcharge: People whose taxable income is greater than a specified
amount (in the 2011/12 financial year $80,000 for singles and $168,000 for
couples[16]) and who do not have an adequate level of private hospital cover must
pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that
if the people in this income group are forced to pay more money one way or another,
most would choose to purchase hospital insurance with it, with the possibility of a
benefit if they need private hospital treatment – rather than pay it in the form of
extra tax as well as having to meet their own private hospital costs.
The Australian government announced in May 2008 that it proposes to increase the
thresholds, to $100,000 for singles and $150,000 for families. These changes
require legislative approval. A bill to change the law has been introduced but was
not passed by the Senate.[17] An amended version was passed on 16 October 2008.
There have been criticisms that the changes will cause many people to drop their
private health insurance, causing a further burden on the public hospital system,
and a rise in premiums for those who stay with the private system. Other
commentators believe the effect will be minimal.[18]
Private Health Insurance Rebate: The government subsidises the premiums for all
private health insurance cover, including hospital and ancillary (extras), by 10%,
20% or 30%, depending on age. The Rudd Government announced in May 2009 that as of
July 2010, the Rebate would become means-tested, and offered on a sliding scale.
While this move (which would have required legislation) was defeated in the Senate
at the time, in early 2011 the Gillard Government announced plans to reintroduce
the legislation after the Opposition loses the balance of power in the Senate. The
ALP and Greens have long been against the rebate, referring to it as "middle-class
welfare".[19]
Canada
Main article: Health care in Canada
As per the Constitution of Canada, health care is mainly a provincial government
responsibility in Canada (the main exceptions being federal government
responsibility for services provided to aboriginal peoples covered by treaties, the
Royal Canadian Mounted Police, the armed forces, and Members of Parliament).
Consequently, each province administers its own health insurance program. The
federal government influences health insurance by virtue of its fiscal powers – it
transfers cash and tax points to the provinces to help cover the costs of the
universal health insurance programs. Under the Canada Health Act, the federal
government mandates and enforces the requirement that all people have free access
to what are termed "medically necessary services," defined primarily as care
delivered by physicians or in hospitals, and the nursing component of long-term
residential care. If provinces allow doctors or institutions to charge patients for
medically necessary services, the federal government reduces its payments to the
provinces by the amount of the prohibited charges. Collectively, the public
provincial health insurance systems in Canada are frequently referred to as
Medicare.[20] This public insurance is tax-funded out of general government
revenues, although British Columbia and Ontario levy a mandatory premium with flat
rates for individuals and families to generate additional revenues – in essence, a
surtax. Private health insurance is allowed, but in six provincial governments only
for services that the public health plans do not cover (for example, semi-private
or private rooms in hospitals and prescription drug plans). Four provinces allow
insurance for services also mandated by the Canada Health Act, but in practice,
there is no market for it. All Canadians are free to use private insurance for
elective medical services such as laser vision correction surgery, cosmetic
surgery, and other non-basic medical procedures. Some 65% of Canadians have some
form of supplementary private health insurance; many of them receive it through
their employers.[21] Private-sector services not paid for by the government account
for nearly 30 percent of total health care spending.[22]

In 2005, the Supreme Court of Canada ruled, in Chaoulli v. Quebec, that the
province's prohibition on private insurance for health care already insured by the
provincial plan violated the Quebec Charter of Rights and Freedoms, and in
particular, the sections dealing with the right to life and security, if there were
unacceptably long wait times for treatment, as was alleged in this case. The ruling
has not changed the overall pattern of health insurance across Canada, but has
spurred on attempts to tackle the core issues of supply and demand and the impact
of wait times.[23]

China
Main articles: Healthcare reform in the People's Republic of China and
Pharmaceutical industry in the People's Republic of China
Cyprus
In 2020 in Cyprus introduced the General Healthcare System (GHS, also known as
GESY) which is an independent insurance fund through which clinics, private
doctors, pharmacists, laboratories, microbiological laboratories, and
physiotherapists will be paid so that they can offer medical care to permanent
residents of Cyprus who will be paying contributions to this fund.[citation needed]

In addition to GESY, more than 12 local and international insurance companies (e.g.
Bupa, Aetna, Cigna, Metlife) provide individual and group medical insurance plans.
The plans are divided into two main categories plans providing coverage from
inpatient expenses (i.e. hospitalization, operations) and plans covering inpatient
and outpatient expenses (such as doctor visits, medications, physio-therapies).
[citation needed]

France
Main article: Health care in France
The national system of health insurance was instituted in 1945, just after the end
of the Second World War. It was a compromise between Gaullist and Communist
representatives in the French parliament. The Conservative Gaullists were opposed
to a state-run healthcare system, while the Communists were supportive of a
complete nationalisation of health care along a British Beveridge model.[citation
needed]

The resulting programme is profession-based: all people working are required to pay
a portion of their income to a not-for-profit health insurance fund, which
mutualises the risk of illness, and which reimburses medical expenses at varying
rates. Children and spouses of insured people are eligible for benefits, as well.
Each fund is free to manage its own budget, and used to reimburse medical expenses
at the rate it saw fit, however following a number of reforms in recent years, the
majority of funds provide the same level of reimbursement and benefits.[citation
needed]

The government has two responsibilities in this system.

The first government responsibility is the fixing of the rate at which medical
expenses should be negotiated, and it does so in two ways: The Ministry of Health
directly negotiates prices of medicine with the manufacturers, based on the average
price of sale observed in neighboring countries. A board of doctors and experts
decides if the medicine provides a valuable enough medical benefit to be reimbursed
(most medicine is reimbursed, including homeopathy). In parallel, the government
fixes the reimbursement rate for medical services: this means that a doctor is free
to charge the fee that he wishes for a consultation or an examination, but the
social security system will only reimburse it at a pre-set rate. These tariffs are
set annually through negotiation with doctors' representative organisations.
The second government responsibility is oversight of the health-insurance funds, to
ensure that they are correctly managing the sums they receive, and to ensure
oversight of the public hospital network.
Today, this system is more or less intact. All citizens and legal foreign residents
of France are covered by one of these mandatory programs, which continue to be
funded by worker participation. However, since 1945, a number of major changes have
been introduced. Firstly, the different health care funds (there are five: General,
Independent, Agricultural, Student, Public Servants) now all reimburse at the same
rate. Secondly, since 2000, the government now provides health care to those who
are not covered by a mandatory regime (those who have never worked and who are not
students, meaning the very rich or the very poor). This regime, unlike the worker-
financed ones, is financed via general taxation and reimburses at a higher rate
than the profession-based system for those who cannot afford to make up the
difference. Finally, to counter the rise in health care costs, the government has
installed two plans, (in 2004 and 2006), which require insured people to declare a
referring doctor in order to be fully reimbursed for specialist visits, and which
installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of
medicine prescribed, and a fee of €16–18 per day for hospital stays and for
expensive procedures.[citation needed]

An important element of the French insurance system is solidarity: the more ill a
person becomes, the less the person pays. This means that for people with serious
or chronic illnesses, the insurance system reimburses them 100% of expenses, and
waives their co-pay charges.[citation needed]

Finally, for fees that the mandatory system does not cover, there is a large range
of private complementary insurance plans available. The market for these programs
is very competitive, and often subsidised by the employer, which means that
premiums are usually modest. 85% of French people benefit from complementary
private health insurance.[24]

Germany
Main article: Healthcare in Germany
Germany has the world's oldest national social health insurance system,[25] with
origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.[26][27]

Beginning with 10% of blue-collar workers in 1885, mandatory insurance has

expanded; in 2009, insurance was made mandatory on all citizens, with private
health insurance for the self-employed or above an income threshold.[28][29] As of
2016, 85% of the population is covered by the compulsory Statutory Health Insurance
(SHI)[30] (Gesetzliche Krankenversicherung or GKV), with the remainder covered by
private insurance (Private Krankenversicherung or PKV). Germany's health care
system was 77% government-funded and 23% privately funded as of 2004.[31] While
public health insurance contributions are based on the individual's income, private
health insurance contributions are based on the individual's age and health
condition.[28][32]

Reimbursement is on a fee-for-service basis, but the number of physicians allowed

to accept Statutory Health Insurance in a given locale is regulated by the
government and professional societies.[citation needed]

Co-payments were introduced in the 1980s in an attempt to prevent over utilization.

The average length of hospital stay in Germany has decreased in recent years from
14 days to 9 days, still considerably longer than average stays in the United
States (5 to 6 days).[33][34] Part of the difference is that the chief
consideration for hospital reimbursement is the number of hospital days as opposed
to procedures or diagnosis. Drug costs have increased substantially, rising nearly
60% from 1991 through 2005. Despite attempts to contain costs, overall health care
expenditures rose to 10.7% of GDP in 2005, comparable to other western European
nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).
[35]

Germans are offered three kinds of social security insurance dealing with the
physical status of a person and which are co-financed by employer and employee:
health insurance, accident insurance, and long-term care insurance. Long-term care
insurance (Gesetzliche Pflegeversicherung) emerged in 1994 and is mandatory.[29]
Accident insurance (gesetzliche Unfallversicherung) is covered by the employer and
basically covers all risks for commuting to work and at the workplace.[36]

Greece
The National Health System in Greece covers both out and in-patient treatment.[37]
The out-patient treatment is carried out by social administrative structures as
following:

EOPPY (National Organization for the Provision of Health Services): contracted

private healthcare providers
PEDY (National Primary Healthcare Network) units: public healthcare
State hospitals, rural and regional medical units, health centers of the ESY
(National Health System)
Private health professionals: Medical professionals and services not contracted
with EOPYY.
The in-patient treatment is carried out by:

State hospitals of the National Health System (ESY).

Private Clinics contracted with the National Health Carrier (EOPYY)
Private hospitals and clinics that are not contracted with the National Health
Carrier.
In Greece anyone can cover the hospitalization expenses using a private insurance
policy, that can be bought by any of the local or multinational insurance companies
that operate in the region (e.g. Metlife, Interamerican, Aetna, IMG).[38]

India
Main article: Healthcare in India
In India, provision of healthcare services and their efficiency varies state-wise.
Public health services are prominent in most of the regions with the national
government playing an important role in funding, framing and implementing policies
and operating public health insurances.

The vast majority of Indians are covered by either a comprehensive public health
insurance scheme run by the National Health Authority called the Ayushman Bharat
Yojana or a private health insurance scheme providing comprehensive coverage and
that is tightly regulated by the Insurance Regulatory and Development Authority of
India.[39]

Japan
Main article: Health care system in Japan
There are three major types of insurance programs available in Japan: Employee
Health Insurance (健康保険 Kenkō-Hoken), National Health Insurance (国民健康保険 Kokumin-
Kenkō-Hoken), and the Late-stage Elderly Medical System (後期高齢医療制度 Kouki-Kourei-
Iryouseido).[40] Although private health insurance is available, all Japanese
citizens, permanent residents, and non-Japanese with a visa lasting one year or
longer are required to be enrolled in either National Health Insurance or Employee
Health Insurance. National Health Insurance is designed for those who are not
eligible for any employment-based health insurance program. The Late-stage Elderly
Medical System is designed for people who are age 75 and older.[[[Health
insurance#Japan#{{{section}}}|contradictory]]][41]

National Health Insurance is organised on a household basis. Once a household has

applied, the entire family is covered. Applicants receive a health insurance card,
which must be used when receiving treatment at a hospital. There is a required
monthly premium, but co-payments are standardized so payers are only expected to
cover ten to thirty percent of the cost, depending on age.[42][non-primary source
needed] If out-of-pocket costs exceed pre-determined limits, payers may apply for a
rebate from the National Health Insurance program.[40]

Employee Health Insurance covers diseases, injuries, and death regardless of

whether an incident occurred at a workplace. Employee Health Insurance covers a
maximum of 180 days of medical care per year for work-related diseases or injuries
and 180 days per year for other diseases or injuries. Employers and employees must
contribute evenly to be covered by Employee Health Insurance.[43]

The Late-stage Elderly Medical System began in 1983 following the Health Care for
the Aged Law of 1982. It allowed many health insurance systems to offer financial
assistance to elderly people. There is a medical coverage fee. To be eligible,
those insured must be either: older than 70, or older than 65 with a recognized
disability.[[[Health insurance#Japan#{{{section}}}|contradictory]]] The Late-stage
Elderly Medical System includes preventive and standard medical care.[43]

healthcare expenditure in Japan by age group

Issues of the healthcare system
Due to Japan's aging population, the Late-stage Elderly Medical System represents
one third of the country's total healthcare cost. When retiring employees shift
from Employee Health Insurance to the Late-stage Elderly Medical System, the
national cost of health insurance is expected to increase since individual
healthcare costs tend to increase with age.[44]

Netherlands
Main article: Health care in the Netherlands
In 2006, a new system of health insurance came into force in the Netherlands. This
new system avoids the two pitfalls of adverse selection and moral hazard associated
with traditional forms of health insurance by using a combination of regulation and
insurance equalization pool. Moral hazard is avoided by mandating that insurance
companies provide at least one policy that meets a government set minimum standard
level of coverage, and all adult residents are obliged by law to purchase this
coverage from an insurance company of their choice. All insurance companies receive
funds from the equalization pool to help cover the cost of this government-mandated
coverage. This pool is run by a regulator which collects salary-based contributions
from employers, which make up about 50% of all health care funding, and funding
from the government to cover people who cannot afford health care, which makes up
an additional 5%.[45]

The remaining 45% of health care funding comes from insurance premiums paid by the
public, for which companies compete on price, though the variation between the
various competing insurers is only about 5%. However, insurance companies are free
to sell additional policies to provide coverage beyond the national minimum. These
policies do not receive funding from the equalization pool but cover additional
treatments, such as dental procedures and physiotherapy, which are not paid for by
the mandatory policy.[45]

Funding from the equalization pool is distributed to insurance companies for each
person they insure under the required policy. However, high-risk individuals get
more from the pool, and low-income persons and children under 18 have their
insurance paid for entirely. Because of this, insurance companies no longer find
insuring high-risk individuals an unappealing proposition, avoiding the potential
problem of adverse selection.[citation needed]

Insurance companies are not allowed to have co-payments, caps, or deductibles, or

deny coverage to any person applying for a policy, or charge anything other than
their nationally set and published standard premiums. Therefore, every person
buying insurance will pay the same price as everyone else buying the same policy,
and every person will get at least the minimum level of coverage. This applies to
all people permanently living and working in the Netherlands. International
students that move to the Netherlands for study purposes have to take out
compulsory Dutch health insurance if they also decide to work (zero-hour contracts
included) or do a paid internship during their stay. In that case, they'll need to
take out the compulsory basic package of Dutch health insurance. Additional
insurance is optional, depending on the student's personal needs.[46][47]

New Zealand
Main article: Health care in New Zealand
Since 1974, New Zealand has had a system of universal no-fault health insurance for
personal injuries through the Accident Compensation Corporation (ACC). The ACC
scheme covers most of the costs of related to treatment of injuries acquired in New
Zealand (including overseas visitors) regardless of how the injury occurred, and
also covers lost income (at 80 percent of the employee's pre-injury income) and
costs related to long-term rehabilitation, such as home and vehicle modifications
for those seriously injured. Funding from the scheme comes from a combination of
levies on employers' payroll (for work injuries), levies on an employee's taxable
income (for non-work injuries to salary earners), levies on vehicle licensing fees
and petrol (for motor vehicle accidents), and funds from the general taxation pool
(for non-work injuries to children, senior citizens, unemployed people, overseas
visitors, etc.)

Rwanda
Main article: Healthcare in Rwanda
Rwanda is one of a handful of low income countries that has implemented community-
based health insurance schemes in order to reduce the financial barriers that
prevent poor people from seeking and receiving needed health services. This scheme
has helped reach 90% of the country's population with health care coverage.[48][49]

Singapore
Main article: Healthcare in Singapore
Singaporeans have one of the longest life expectancy at birth in the world. During
this long life, encountering uncertain situations requiring hospitalization are
inevitable. Health insurance or medical insurance cover high healthcare costs
during hospitalization.[50]

Health insurance for Singapore Citizens and Permanent Residents

MediShield Life, is a universal health insurance covering all Singapore Citizens

and Permanent Residents. MediShield Life covers hospitalization costs for a stay in
ward B2 or C in a Public hospital. For the hospitalization in a Private hospital,
or in ward A or B1 in Public hospital, MediShield Life coverage is pegged to B2 or
C ward prices and insured is required to pay the remaining bill amount. This
remaining bill amount can be paid using MediSave but limits are applied on the
MediSave usage. MediShield Life does not cover overseas medical expenses and the
treatment of serious pre-existing illnesses for which one has been receiving
treatment during the 12 months before the start of the MediShield Life coverage.
MediShield Life also does not cover treatment of congenital anomalies (medical
conditions that are present at birth), cosmetic surgery, pregnancy-related charges
and mental illness.[51]

As the MediShield Life benefits are capped for B2 or C ward hospitalization in

public hospitals, Integrated Shield plans provide coverage for the hospitalization
in private hospitals, or ward A or B1 in public hospitals.[52] Integrated Shield
insurance plans cover large hospitalization bills for Private hospitals or, ward A
or B1.[52] However, insured is still required to pay a portion of the bill amount.
This is in accordance with Singapore's healthcare philosophy which promotes
personal responsibility with getting individuals to share the cost of healthcare.
With this philosophy, deductible, co-insurance and peroration are applied on most
of the Health Insurance plans in Singapore. Such health insurance plans provide an
option to purchase a health insurance rider to cover these charges.[53]

Health insurance for Foreigners in Singapore

Unlike Singapore Citizens and Permanent Residents, Foreigners are not automatically
covered by the MediShield Life. Foreigners can purchase the health insurance plans
from several life insurers in Singapore.[53]

South Korea
Main article: Healthcare in South Korea
South Korea's life expectancy at birth was 82.7 years in 2017, higher than the OECD
average of 80.8. Men's life expectancy was 79.7 years, higher than the OECD average
of 78.1 years, and women's life expectancy was 85.7 years, higher than the average
of 83.4 years.[54]

Health care in South Korea is provided by the National Health Insurance (NHI),
which is mandatory. Anyone residing in South Korea, regardless of nationality or
occupation, can purchase this insurance.[55]

Switzerland
Main article: Health insurance in Switzerland
Healthcare in Switzerland is universal[56] and is regulated by the Swiss Federal
Law on Health Insurance. Health insurance is compulsory for all persons residing in
Switzerland (within three months of taking up residence or being born in the
country).[57][58] It is therefore the same throughout the country and avoids double
standards in healthcare. Insurers are required to offer this basic insurance to
everyone, regardless of age or medical condition. They are not allowed to make a
profit off this basic insurance, but can on supplemental plans.[56]

The universal compulsory coverage provides for treatment in case of illness or

accident and pregnancy. Health insurance covers the costs of medical treatment,
medication and hospitalization of the insured. However, the insured person pays
part of the costs up to a maximum, which can vary based on the individually chosen
plan, premiums are then adjusted accordingly. The whole healthcare system is geared
towards to the general goals of enhancing general public health and reducing costs
while encouraging individual responsibility.[citation needed]

The Swiss healthcare system is a combination of public, subsidized private and

totally private systems. Insurance premiums vary from insurance company to company,
the excess level individually chosen (franchise), the place of residence of the
insured person and the degree of supplementary benefit coverage chosen
(complementary medicine, routine dental care, semi-private or private ward
hospitalization, etc.).[citation needed]

The insured person has full freedom of choice among the approximately 60 recognized
healthcare providers competent to treat their condition (in their region) on the
understanding that the costs are covered by the insurance up to the level of the
official tariff. There is freedom of choice when selecting an insurance company to
which one pays a premium, usually on a monthly basis. The insured person pays the
insurance premium for the basic plan up to 8% of their personal income. If a
premium is higher than this, the government gives the insured person a cash subsidy
to pay for any additional premium.

The compulsory insurance can be supplemented by private "complementary" insurance

policies that allow for coverage of some of the treatment categories not covered by
the basic insurance or to improve the standard of room and service in case of
hospitalization. This can include complementary medicine, routine dental treatment
and private ward hospitalization, which are not covered by the compulsory
insurance.

As far as the compulsory health insurance is concerned, the insurance companies

cannot set any conditions relating to age, sex or state of health for coverage.
Although the level of premium can vary from one company to another, they must be
identical within the same company for all insured persons of the same age group and
region, regardless of sex or state of health. This does not apply to complementary
insurance, where premiums are risk-based.

Switzerland has an infant mortality rate of about 3.6 out of 1,000. The general
life expectancy in 2012 was for men 80.5 years compared to 84.7 years for women.
[59] These are the world's best figures.[60]
United Kingdom
Main article: National Health Service
The UK's National Health Service (NHS) is a publicly funded healthcare system that
provides coverage to everyone normally resident in the UK. It is not strictly an
insurance system because (a) there are no premiums collected, (b) costs are not
charged at the patient level and (c) costs are not pre-paid from a pool. However,
it does achieve the main aim of insurance which is to spread financial risk arising
from ill-health. The costs of running the NHS (est. £104 billion in 2007–8)[61] are
met directly from general taxation. The NHS provides the majority of health care in
the UK, including primary care, in-patient care, long-term health care,
ophthalmology, and dentistry.

Private health care has continued parallel to the NHS, paid for largely by private
insurance, but it is used by less than 8% of the population, and generally as a
top-up to NHS services. There are many treatments that the private sector does not
provide. For example, health insurance on pregnancy is generally not covered or
covered with restricting clauses. Typical exclusions for Bupa schemes (and many
other insurers) include:

aging, menopause and puberty; AIDS/HIV; allergies or allergic disorders; birth

control, conception, sexual problems and sex changes; chronic conditions;
complications from excluded or restricted conditions/ treatment; convalescence,
rehabilitation and general nursing care ; cosmetic, reconstructive or weight loss
treatment; deafness; dental/oral treatment (such as fillings, gum disease, jaw
shrinkage, etc.); dialysis; drugs and dressings for out-patient or take-home use† ;
experimental drugs and treatment; eyesight; HRT and bone densitometry; learning
difficulties, behavioural and developmental problems; overseas treatment and
repatriation; physical aids and devices; pre-existing or special conditions;
pregnancy and childbirth; screening and preventive treatment; sleep problems and
disorders; speech disorders; temporary relief of symptoms.[62] († = except in
exceptional circumstances)

There are a number of other companies in the United Kingdom which include, among
others, Chubb Limited, AXA, Aviva, Bupa, Groupama Healthcare, WPA and
VitalityHealth. Similar exclusions apply, depending on the policy which is
purchased.

In 2009, the main representative body of British Medical physicians, the British
Medical Association, adopted a policy statement expressing concerns about
developments in the health insurance market in the UK. In its Annual Representative
Meeting which had been agreed earlier by the Consultants Policy Group (i.e. Senior
physicians) stating that the BMA was "extremely concerned that the policies of some
private healthcare insurance companies are preventing or restricting patients
exercising choice about (i) the consultants who treat them; (ii) the hospital at
which they are treated; (iii) making top up payments to cover any gap between the
funding provided by their insurance company and the cost of their chosen private
treatment." It went in to "call on the BMA to publicise these concerns so that
patients are fully informed when making choices about private healthcare
insurance."[63] The practice of insurance companies deciding which consultant a
patient may see as opposed to GPs or patients is referred to as Open Referral.[64]
The NHS offers patients a choice of hospitals and consultants and does not charge
for its services.

The private sector has been used to increase NHS capacity despite a large
proportion of the British public opposing such involvement.[65] According to the
World Health Organization, government funding covered 86% of overall health care
expenditures in the UK as of 2004, with private expenditures covering the remaining
14%.[31]
Nearly one in three patients receiving NHS hospital treatment is privately insured
and could have the cost paid for by their insurer. Some private schemes provide
cash payments to patients who opt for NHS treatment, to deter use of private
facilities. A report, by private health analysts Laing and Buisson, in November
2012, estimated that more than 250,000 operations were performed on patients with
private medical insurance each year at a cost of £359 million. In addition, £609
million was spent on emergency medical or surgical treatment. Private medical
insurance does not normally cover emergency treatment but subsequent recovery could
be paid for if the patient were moved into a private patient unit.[66]

United States
Main articles: Health insurance in the United States and Health care in the United
States
Short Term Health Insurance

On the 1st of August, 2018 the DHHS issued a final rule which made federal changes
to Short-Term, Limited-Duration Health Insurance (STLDI) which lengthened the
maximum contract term to 364 days and renewal for up to 36 months.[67][68] This new
rule, in combination with the expiration of the penalty for the Individual Mandate
of the Affordable Care Act,[69] has been the subject of independent analysis.[70]
[71][72][73][74][75][76][77]

The United States health care system relies heavily on private health insurance,
which is the primary source of coverage for most Americans. As of 2018, 68.9% of
American adults had private health insurance, according to The Center for Disease
Control and Prevention.[78] The Agency for Healthcare Research and Quality (AHRQ)
found that in 2011, private insurance was billed for 12.2 million U.S. inpatient
hospital stays and incurred approximately $112.5 billion in aggregate inpatient
hospital costs (29% of the total national aggregate costs).[79] Public programs
provide the primary source of coverage for most senior citizens and for low-income
children and families who meet certain eligibility requirements. The primary public
programs are Medicare, a federal social insurance program for seniors and certain
disabled individuals; and Medicaid, funded jointly by the federal government and
states but administered at the state level, which covers certain very low income
children and their families. Together, Medicare and Medicaid accounted for
approximately 63 percent of the national inpatient hospital costs in 2011.[79]
SCHIP is a federal-state partnership that serves certain children and families who
do not qualify for Medicaid but who cannot afford private coverage. Other public
programs include military health benefits provided through TRICARE and the Veterans
Health Administration and benefits provided through the Indian Health Service. Some
states have additional programs for low-income individuals.[80]

In the late 1990s and early 2000s, health advocacy companies began to appear to
help patients deal with the complexities of the healthcare system. The complexity
of the healthcare system has resulted in a variety of problems for the American
public. A study found that 62 percent of persons declaring bankruptcy in 2007 had
unpaid medical expenses of $1000 or more, and in 92% of these cases the medical
debts exceeded $5000. Nearly 80 percent who filed for bankruptcy had health
insurance.[81] The Medicare and Medicaid programs were estimated to soon account
for 50 percent of all national health spending.[82] These factors and many others
fueled interest in an overhaul of the health care system in the United States. In
2010 President Obama signed into law the Patient Protection and Affordable Care
Act. This Act includes an 'individual mandate' that every American must have
medical insurance (or pay a fine). Health policy experts such as David Cutler and
Jonathan Gruber, as well as the American medical insurance lobby group America's
Health Insurance Plans, argued this provision was required in order to provide
"guaranteed issue" and a "community rating," which address unpopular features of
America's health insurance system such as premium weightings, exclusions for pre-
existing conditions, and the pre-screening of insurance applicants. During 26–28
March, the Supreme Court heard arguments regarding the validity of the Act. The
Patient Protection and Affordable Care Act was determined to be constitutional on
28 June 2012. The Supreme Court determined that Congress had the authority to apply
the individual mandate within its taxing powers.[83]

History and evolution

Main articles: Health insurance in the United States § History, and Managed care
In the late 19th century, "accident insurance" began to be available, which
operated much like modern disability insurance.[84][85] This payment model
continued until the start of the 20th century in some jurisdictions (like
California), where all laws regulating health insurance actually referred to
disability insurance.[86]

Accident insurance was first offered in the United States by the Franklin Health
Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance
against injuries arising from railroad and steamboat accidents. Sixty organizations
were offering accident insurance in the U.S. by 1866, but the industry consolidated
rapidly soon thereafter. While there were earlier experiments, the origins of
sickness coverage in the U.S. effectively date from 1890. The first employer-
sponsored group disability policy was issued in 1911.[87]

Before the development of medical expense insurance, patients were expected to pay
health care costs out of their own pockets, under what is known as the fee-for-
service business model. During the middle-to-late 20th century, traditional
disability insurance evolved into modern health insurance programs. One major
obstacle to this development was that early forms of comprehensive health insurance
were enjoined by courts for violating the traditional ban on corporate practice of
the professions by for-profit corporations.[88] State legislatures had to intervene
and expressly legalize health insurance as an exception to that traditional rule.
Today, most comprehensive private health insurance programs cover the cost of
routine, preventive, and emergency health care procedures. They also cover or
partially cover the cost of certain prescription and over-the-counter drugs.
Insurance companies determine what drugs are covered based on price, availability,
and therapeutic equivalents. The list of drugs that an insurance program agrees to
cover is called a formulary.[7] Additionally, some prescriptions drugs may require
a prior authorization[89] before an insurance program agrees to cover its cost.

The numbers of Americans lacking health insurance and the uninsured rate from 1987
to 2008
Hospital and medical expense policies were introduced during the first half of the
20th century. During the 1920s, individual hospitals began offering services to
individuals on a pre-paid basis, eventually leading to the development of Blue
Cross organizations.[87] The predecessors of today's Health Maintenance
Organizations (HMOs) originated beginning in 1929, through the 1930s and on during
World War II.[90][91]

The Employee Retirement Income Security Act of 1974 (ERISA) regulated the operation
of a health benefit plan if an employer chooses to establish one, which is not
required. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) gives
an ex-employee the right to continue coverage under an employer-sponsored group
health benefit plan.

Through the 1990s, managed care insurance schemes including health maintenance
organizations (HMO), preferred provider organizations, or point of service plans
grew from about 25% US employees with employer-sponsored coverage to the vast
majority.[92] With managed care, insurers use various techniques to address costs
and improve quality, including negotiation of prices ("in-network" providers),
utilization management, and requirements for quality assurance such as being
accredited by accreditation schemes such as the Joint Commission and the American
Accreditation Healthcare Commission.[93]

Employers and employees may have some choice in the details of plans, including
health savings accounts, deductible, and coinsurance. As of 2015, a trend has
emerged for employers to offer high-deductible plans, called consumer-driven
healthcare plans which place more costs on employees, while employees benefit by
paying lower monthly premiums. Additionally, having a high-deductible plan allows
employees to open a health savings account, which allows them to contribute pre-tax
savings towards future medical needs. Some employers will offer multiple plans to
their employees.[94]

Russia
See also: Healthcare in Russia
The private health insurance market, known in Russian as "voluntary health
insurance" (Russian: добровольное медицинское страхование, ДМС) to distinguish it
from state-sponsored Mandatory Medical Insurance, has experienced sustained levels
of growth.[95] It was introduced in October 1992.[96]

Taiwan
Main article: Healthcare in Taiwan
See also
ANSI 834 Enrollment Implementation Format
Economic capital
Health administration
Health Advocate (a US-based patient advocacy company)
Health system – cross-national comparisons
Health care reform
Healthcare in Costa Rica
Health Insurance Innovations
Health crisis
Health economics
Health insurance marketplace
Health insurance mandate
Hospital accreditation
International healthcare accreditation
Nyman's model
Philosophy of healthcare
Prescription analytics
[Link] (a US lobbying group)
Public health
Quality-adjusted life year
Self-funded health care
Single-payer healthcare
Social security
Welfare
The Hospital Uninsured Patient Discount Act (Illinois)
Universal Declaration of Human Rights
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